Community-based follow up Telephone contacts were made to the infants' primary caregiver by the nurse specialist twice weekly in the first month after discharge, weekly in months two through four, and monthly thereafter until the infant attained 12 months adjusted age. At each telephone contact, the nurse used a semi-structured format to inquire about the infant's health, community resources utilized by the infant, and potential stressors and sources of support for the family. She also inquired about the infant's medications and feedings. If she judged the infant would benefit from a change in medical management, additional assessments or a subspecialty referral, she discussed the proposed change with one of the two study neonatologists. If there was agreement, the recommendation was communicated to the family and the infant's primary care provider. The nurse specialist also coordinated care for the infant by communicating with home health nurses, public health nurses, early intervention specialists, physical therapists, and pediatric sub-specialists.